P.O. Box 343, Cornwall, ON K6J 5T1
Tel & Fax: 1-877-268-2211
autismcornwall@gmail.com
www.autismontario.com/uppercanada
REGISTRATION FORM
Date Completed:
Session Dates:
Participant’s Full Name
Age
Gender
Diagnosis
Parent/Guardian Name(s)
Address
Person(s) authorized to pick child up from program:
Parent(s)/Guardian(s) as named above, and/or
Program Cost:
$45.00 (for 6 sessions, AO-UCC members)
$90.00 (for 6 sessions, non-members)
Payment methods:
Cash
Cheque (please make payable to Autism Ontario)
EMERGENCY CONTACT INFORMATION
Participant’s Full Name
Physician’s name
Phone
OHIP#
#1 Emergency Contact Person
Relationship to participant
Telephone #’s
Home
Cellular
Work
Cellular
Work
#2 Emergency Contact Person
Relationship to participant
Telephone #’s
Home
Participant’s Condition or Disability
ANY allergies (food etc)
ANY dietary concerns
ANY medical information:
PARTICIPANT PROFILE
Participant’s Full Name
Does your child utilize any of the following? (check, or highlight in bold)
□
PECS
□
Sign Language
□
Visual Schedules
□
Social Stories/Scripts
□
Choice Boards
□
Fidget/Stimmy Toys
□
Relaxation methods
□
Problem Solving Worksheets
□
Other ___________________________________________
Please describe your child’s self-help skills (check, or highlight in bold):
Complete Assistance
Toileting
Dressing
Eating
Partial Assistance
1
1
1
Does your child exhibit any of the following?
Never
1
Self-stimulatory behaviours
2
Perseverative play or rituals
3
Reaction to change
4
Runs away
5
Scratches, bites or hits self
6
Scratches, bites or hits others
7
Screams
8
Touches other inappropriately
9
Other
Independent
2
2
2
Rarely
3
3
3
Sometimes
Often
Please briefly describe situations where items 1 to 9 above may occur and what positive
interventions help resolve the situation:
Does your child have difficulty with new environments, unfamiliar people, changes in routine? If so, how
is it displayed?
(check, or highlight in bold)  Yes
 No
If yes, please explain:
Please indicate strategies used to ease transitions:
Does your child have difficulty tolerating specific physical environments (noise level, number of people,
furniture, room size, lighting, closed doors, low ceiling, mirrors, windows etc.)
(check, or highlight in bold)
 Yes
 No
If yes, please explain:
Does your child seem to get frustrated easily, and if so, how is this frustration displayed?
(check, or highlight in bold)
 Yes
 No
If yes, please explain:
How long would you estimate your child can engage in an activity before becoming distracted or
uninterested?
 0-5 minutes
 5-10 minutes  10-15 minutes
 15+ minutes
Are you currently, or have you ever implemented any specific behavioural guidelines/programs at home
or at your child's school?
(check, or highlight in bold)  Yes  No If yes, please explain:
Does your child have any fears?
 Yes  No
If yes, please explain:
Does your child have any special interests, favourite tv characters or games? (please use extra sheet if
necessary)
(check, or highlight in bold)  Yes  No
If yes, please explain:
What are some things your child enjoys (potential reinforcers). Please describe:
Activities: (praise, high fives, attention from others, etc.):
Objects: (food, toys, stickers etc.):
Sensory (rocking, jumping, experiencing different textures etc.):
Please indicate any additional behavioural concerns and/or interventions (use extra sheet if necessary):
Communication / Social Skills:
Does your child: (please indicate Y or N)
Engage in solitary play?
Call attention to others?
Play with same toy along side peers?
Converse with peers/adults?
Engage in group play?
Request a break when upset?
Share materials?
Express feelings?
Turn take with peers?
Indicate relaxation?
Comment on environment or the unexpected?
Requests assistance?
Make requests for basic wants and needs?
Indicate likes/dislikes?
Follow non-verbal directions?
Express confusion (“I don’t know”)
Follow verbal directions within familiar routines?
Make transitions?
Follow verbal directions within novel activities?
Recognize personal belongings?
Utilize visual supports to follow directions?
Organize needed materials for outings?
Require processing time to follow directions?
Make choices?
Wait when directed?
Does your child attend: (please indicate Y or N)
Grocery Store
Playground
Toy Store
Doctor
Fast Food Restaurant
Dentist
Sit Down Restaurant
Barber/Hair Salon
Movies
Birthday Parties/Holidays
Swimming
Friend’s House
Organized Sports